1. ICD-10-CM Coding Guidelines
Dawn Goodsell, RHIA, CCS, CPC-I, CPC,COC

2. Chapter 1 Infectious Disease A00-B99
Beginning of Chapter 1 in Tab sections states
“Use an additional code to identify resistance to antimicrobial drug (Z16)). Use this code when assigning any code from this chapter.
Under category B39, histoplasmosis there is a note that states:
Use an additional code for any associated manifestation.
New section called Infections with a Predominantly Sexual Mode of Transmission (A50-A64).
Sequelae of Infectious and Parasitic Diseases (B90-B94)
Use to indicate conditions in Categories (A00-B89) as cause of the sequelae.

3. Coding Example:
A 90-year-old female patient was seen with fever and lower back pain. A urinalysis was performed and showed bacteria infection. A culture was performed which showed growth of E.coli as the cause of this UTI.
Assign DX Codes:
Answer: N39.0- Infection down to urinary tract , check tab section to verify
B Infection down to Escherichia Coli or E. coli down to as cause of the disease classified elsewhere.

4. Guideline 1.c.1.C Infections Resistance to Antibiotics
Some infections are resistant to antibiotics.
Category Z16
Follow infection code to specify resistance
Some infections are resistant to antibiotics. You need to identify all infections that are resistant to antibiotics.
Category Z16 will state resistance to antimicrobial drugs
This code should follow the infection code only if the infection code does not identify drug resistance

5. Coding Example:
A 90-year-old gentleman is seen for C.diff colitis. Cultures of the organism have found this infection to be resistant to the antibiotic called flagyl. We are starting a new drug regimen.
Code the dx:
Codes: A04.7- colitis down to Clostridium difficile ; tab section to check characters
Z resistance down to antimicrobial down to specified (flagyl) ; tab section to check characters

6. Coding Guideline I.B.10 Sequela (Late Effects)
Sequela is the residual effect after the acute condition or illness has cleared up.
Sequela can be anytime after the condition occurrence
Can be apparent right after
May occur months or years after
Coding for sequela is as follows
Nature of sequela first ( reason for being seen or sickness)
Condition or nature of the sequela is sequenced second ( cause of the sickness)

7. Coding Example:
A patient presents with right lower leg pain and muscle atrophy. Patient had a confirmed case of polio as a child.
Codes:
M Atrophy, down to muscle, down to lower leg M ; tab section to check the characters
B91- Late effect says see sequelae; sequelae down to Poliomyelitis B91; tab section to check characters

8. Coding Guideline IC1a.2.a. Patient Admitted for HIV-related Condition
When a patient is admitted with an HIV-related condition
Principal Diagnosis should be B20
This is only for an HIV- related condition
When a patient is admitted with a non-related condition
Code the admitting diagnosis first
Code the HIV code second
Examples of possible scenarios:
Patient admitted with Pneumocystis (carinii) and AIDS
Code the AIDS first; comorbidity is the pneumocystis
Patient admitted left fracture of the head of the femur who has AIDS.
Code fracture first followed by the AIDS

9. Coding Example:
A 50 year old HIV positive female has a fever and trouble breathing. Testing was done and results showed Pneumocystis pneumonia. This was documented due to AIDS.
Codes:
Codes:
B20- Human down to immunodeficiency virus down to disease B20
Tab section to check characters
B59- pneumonia down to pneumocystits (carinii) B59; tab section to check characters

10. Coding Guideline 1.C1.d.1.a Sepsis
When coding for sepsis
Assign code for the underlying systemic infection
If it is not specified assign code A41.9 as sepsis unspecified organism
A code from subcategory R65.2, severe sepsis, should only be coded if:
Severe sepsis is stated
Associated acute organ dysfunction is documented

11. Coding Example:
A 47-year-old patient is being treated with IV antibiotics for E. coli sepsis.
Codes:
Is there one code or 2?
A Sepsis down to Escherichia coli; tab section to verify code and characters
There is no indication of severe sepsis so you would only code for the sepsis itself. There is no indication of organ dysfunction.

12. Coding Guideline 1.C.1.d.1.b Severe Sepsis
Severe sepsis coding requires at least two codes
Code first for the underlying system infection
Code second for the severe sepsis R65.2
Use the unspecified sepsis code of the organism is not stated
Code for R65.2 if organ dysfunction is stated

13. Coding Example:
80-year-old man was taken to the ED after being found incoherent with abnormal vital signs, fever, and respiratory difficulty. After admission to the ICU, the physician diagnosed the patient with severe sepsis and acute respiratory failure. Final diagnosis was gram-negative sepsis with acute respiratory failure .
Codes:
Codes:
A41.50 – Sepsis down to gram-negative; tab section to check characters
R Sepsis, down to severe; this includes organ failure or dysfunction; tab section to check your characters
J Failure down to respiratory down to acute ; tab section to check your characters

14. Coding Guidelines 1.C.1.d.2 Septic Shock
Septic shock can be classified as circulatory failure associated with severe sepsis
It is a type of acute organ dysfunction or failure
When coding for septic shock
Code the systemic infection first
Second code should be R65.21 Severe sepsis with septic shock
You could also add code T81.12 for Post procedural septic shock if indicated

15. Coding Example:
A 30-year-old male was transferred from another facility for treatment of septic shock and acute meningococcal sepsis. The other facility was unable to manage her severe illness.
Codes:
Codes:
A39.2 – sepsis down to meningococcal, down to acute ; tab section to verify characters
R sepsis, down to severe down to septic shock ; tab section to verify characters

16. Coding Guidelines: Chapter 2 Neoplasm 1. C
Coding Guidelines: Chapter 2 Neoplasm 1.C.2 General Neoplasm Guidelines
When looking up neoplasms, the alpha index should be referenced first
Alpha will indicate which column to use when looking at the Neoplasm Table
Overlapping lesions or areas should be coded with subcategory .8 unless indicated elsewhere
Malignant neoplasms of ectopic tissue are to coded to site indicated or organ
Example: ectopic pancreatic malignant neoplasms would be found neoplasm down to pancreas and then unspecified

17. Coding Example:
55 – year-old male patient with small cell carcinoma of the right lower lobe of the lung which metastasized to the intrathoracic lymph nodes, brain, and right rib.
Codes:
Codes:
C carcinoma sends you to neoplasm
Neoplasm down to lung down to lower lobe C34.3; tab section to check characters
C77.1- Neoplasm down to lymph down to gland secondary C77.9; tab section to check characters
C Neoplasm down to brain secondary; tab section to check characters
C Neoplasm down to bone down to rib secondary; tab section to check characters

18. Coding Guideline I.C.2.c.3 Management of Dehydration due to the Malignancy
If patient is admitted for dehydration due to the malignancy or the therapy
If only dehydration is being treated it is coded first
Secondary code is the malignancy

19. Coding Guideline I.C.6.b.5 Neoplasm-Related Pain
Use code G89.3 for pain that is document being related or associated or due to cancer, primary or secondary malignancy or a tumor.
G89.3 is assigned if the pain is acute or it is chronic
If patient is being admitted for the pain due to the cancer, G89.3 is coded first followed by the cancer diagnosis
If the admitting diagnosis is management of the neoplasm and the pain is associated with the neoplasm then code the G89.3 as an additional diagnosis.

20. Coding Example:
A female with terminal cancer of the central portion of the right breast, which spread or metastasized to the liver and the brain, we seen for dehydration and chronic intractable neoplasm-related pain. Patient was given IV fluids and IV pain medication with no treatment directed toward the cancer at that time.
Codes:
Primary Diagnosis: Dehydration E86.0
2nd: Pain G89.3
3rd: CA of the breast; neoplasm down to breast down to central portion down over to primary ; tab section to check the code : C50.111
4th: Neoplasm down to brain over to secondary column C79.31; tab section to check the code
5th: neoplasm down to liver over to secondary column C78.7; tab section to check the code

21. Coding Example:
40-year old female was diagnosed with right breast carcinoma 6 years ago at which time she had a right mastectomy performed with chemotherapy administration. She has been well since that time and in remission only being seen for yearly checkups. Patient is being seen today with visual disturbance, dizziness, headaches, and blurred vision. Testing was done to reveal metastasis to the brain, accounting for these symptoms. This was identified as being metastatic from the breast, not a new primary.
Codes:
Primary dx: Neoplasm down to brain over to secondary C79.31
2nd: History to personal down to malignant breast Z85.3
3rd: Absence down to breast Z90.12
4th: History down to personal down to chemotherapy for neoplastic condition

22. Coding Guidelines: I. C. 2. e
Coding Guidelines: I.C.2.e.2 Patient Admission for administration of chemo, immunotherapy, and radiation therapy
If patient is admitted for administration of chemo, immunotherapy, or radiation therapy
Assign code Z51.0
If a patient being seen for antineoplastic radiation therapy
Assign code Z51.11
If a patient is being seen for antineoplastic immunotherapy as principle diagnosis
Assign code Z51.12
If a patient receives more than one different types of therapy on same admission
Assign for each one of the treatment/therapy that is given

23. Coding Example:
A patient is seen today for chemotherapy due to recent diagnosis of carcinoma of the small intestines. A tumor was excised in the area of the duodenum and jejunum were they join. The procedure was done 3 months ago and the patient has been receiving Chemotherapy since then.
Codes:
Codes:
Principles: Chemotherapy Z51.11; tab section to check the code
2nd: Neoplasm down to intestine down to small, overlapping lesion primary C17.8; tab section to check the code
3rd: Absence down to intestine small Z90.49

24. Coding Guideline: Chapter 3 Diseases of the blood and blood-forming organs and disorders involving the immune Mechanisms
I.C.2.c.1- Anemia associated with Malignancy
If patient is admitted for management of an anemia associated with malignant cancer and the only thing treated is anemia
Code for the malignancy is sequenced as the principal first diagnosis
Anemia is coded as second such as D63.0 Anemia in neoplastic disease

25. Coding Example:
A 65 year old female receives blood transfusion for severe anemia due to her left breast carcinoma.
Code:
Red cell aplastic anemia congenital
Code:
Neoplasm down to breast C for left side
2nd code: anemia down to with neoplastic disease D63.0
2nd Question :
Anemia down to aplastic down to red cell down to congenital D61.01

26. Coding Guidelines: Chapter 4 Endocrine, nutritional and metabolic diseases
I.C.4.a. Diabetes Mellitus
Codes are now combination codes that include DM and comorbidity or body system affected
Or complication of the disease
May need to use more than one DM codes if more than comorbidity exists.
Code all comorbidity codes that apply to treatment and services

27. Coding Example:
A 75-year-old male is being seen for mild nonproliferative diabetic retinopathy with macular edema. Patient has type 2 DM and takes insulin on a daily basis. Patient also has diabetic cataracts in his right eye.
Code
The patient has type 1 diabetes with diabetic chronic kidney disease in stage 3. He is being seen today for regulation of insulin dosage. The patient is being seen today for a an abscess tooth which is causing his blood sugars to be elevated and irregular.
Code:
1st Question:
Principle: Diabetes type 2 down to retinopathy down to nonproliferative down to mild down to macular edema E11.321; tab section to check code
2nd: Diabetes type 2 down to cataract E11.36; tab section to check code
3rd: Long-term drug therapy Z79.4; tab section check code
2nd Question:
Principle: Diabetes type 1 down to with diabetic chronic kidney disease chronic down E10.22 ; tab to check code
2nd: Disease down to kidney down to stage 3 moderate N18.3 ; tab secretion to check code
3rd: abscess down to tooth down to teeth root K04.7; tab section to check code

28. Coding Guideline: I.C.4.a.6 Secondary Diabetes Mellitus
Category E08
DM due to underlying condition
Category E09
Chemical induced DM
Identify the complications and manifestations associated with secondary DM
Secondary DM is always caused by another condition or event
Examples: Cystic Fibrosis, CA of the pancreas, pancreatectomy, adverse of drug, poisoning

29. Code Guideline: I.C.4.a.6.b Assigning and sequencing secondary diabetes codes and its causes
Secondary DM sequencing codes
Relationship to codes for cause of the DM is based on Tabular List Instruction
Category E08 and E09

30. Coding Examples:
A 32-year-old female with secondary DM due to acute idiopathic pancreatitis. She has diabetic hyperglycemia and she is taking insulin for 2 years.
Code:
Obese patient with a BMI of 42 as an adult
Code:
1st Question:
Principle: Pancreatitis down to acute down to idiopathic K85.0; tab section to check your code
2nd: Diabetes down to underlying condition down to with down to hyperglycemia E08.65; tab section to check your code
3rd: Long-term use drug therapy, insulin Z79.4
2nd Question:
Obesity down to morbid E66.01; tab section to check code
3rd: Body down to bodies, mass index down to adult Z68.41

31. Coding Guidelines: I.C.19..5.a Adverse Effect
When you are coding for Adverse effect of a drug
Correctly administered
Code for the nature of the adverse effect (ex. Rash)
Code adverse effect from drug and chemical section (T36-T50) should have 5 characters
Use additional code to identify any insulin use (Z79.4)

32. Coding Example:
A 45 year old patient is being seen ongoing for management of his steroid-induced DM which was due to the prolonged use of corticosteroids, which has been discontinued. The DM is being managed with insulin which he has been taking for the last two years.
Code
A type 1 DM patient ahs a severe chronic diabetic left foot ulcer with diabetic peripheral angiopathy. This patient also has DM stage 2 chronic kidney disease. Patient is being seen today for an ulcer which has breakdown of the skin.
Code:
1st Question:
Principle: DM down due to drug or chemical E09.9; tab to check code
2nd: table of drugs down to corticosteroid over to adverse effect T38.0X5S; tab section to check the code
3rd: long-term drug therapy insulin Z79.4
2nd: Question:
Principle: Diabetes DM type 1 down to foot ulcer E10.621; tab to check code
2nd: Ulcer down to foot says see ulcer lower limb down to lower limb down to foot with skin breakdownL97.521; tab section to check code
3rd: DM type 1 down to peripheral angiopathy E10.51
4th: DM type 1 with chronic kidney disease E10.22
5th: disease down kidney down to chronic down to stage 2 mild N18.2

33. Chapter 5 Mental Behavioral Neuro disorders 1.C.5.b.1
Guideline
Remission – mental and behavioral disorders
Provider determines clinical judgement
In remission
Based on documentation
Due to psychoactive substance use it will require providers clinical judgement.

34. Clinical example- In remission
Jeff, a 50 year old male is currently receiving treatment for alcohol dependence. Due to the drinking, Jeff has developed chronic alcohol gastritis. He also has a history of cocaine dependence.
What are the diagnoses for this patient/

35. Example results Primary dx: F10.20 Dependence , alcohol w/o remission
Secondary:
K29.20 Gastritis, simple, alcoholic
F14.21 History personal drug dependent see dependence\
Dependence, drug, cocaine, in remission

36. Example: In remission
Sally is being seen for individual psychotherapy as part of her long-term treatment for borderline personality disorder. Her condition is described as “cluster B personality disorder”. The patient has been taking his monoamine oxidase inhibitor (MAOI) medication and reports he feels it has helped her manage his impulsive, overly emotional, and erratic behavior. The patient is also a recovering alcoholic which the therapist describes as being “in remission.” The patient will return next week for her scheduled appointment.
What are the diagnoses?

37. Example answer: Primary: F60.3 Disorder, personality borderline
Secondary: F Alcohol, alcoholic, alchohol induced addiction, with remission
Z Long-term current drug therapy NEC

38. Chapter #6 Diseases of the nervous system
Use the following only when the listed condition are reported without further specification or stated that it an old or longstanding but unspecified cause
G81 Hemiplegia and hemiparesis
G82- Paraplegia and quadriplegia
G83- other paralytic syndrome
Term epilepsy has been updated
Epilepsy- includes terms to calssify the disorder such as the following:
Localizaiton-related idiopathic epilepsy
Generalized idiopathic epilepsy
Special epilecptic syndromes
Can also specify as well: localized onset, complex partial seizueres, intractable seizures and status epilepticus.
G40 category is for Epilepsy and recurrent seizures
And G43 is for migraines

39. Example #1
A 55 year old male has been having increasing dementia and forgetfulness. He has been wandering around a lot lately and wondering off such has leaving the home and forgetting where he is or where he is going. He has been diagnosed with dementia due to early-onset Alzheimer’s.
What diagnoses are assigned?

40. Example #1 answer
Primary- G30.0 Alzheimer’s disease or sclerosis, see disease, Alzheimer’s, early onset, with behavioral disturbance
Secondary
F Dementia, in Alzheimer’s disease, see disease, Alzheimer’s
Z Wandering, in diseases classified elsewhere

41. Coding Guideline: 1.C.6.a Dominant/nondominat side
G81- hemiplegia and hemiparesis
G83- upper and lower limb monoplegia
Identify whether the dominant or monodominant side is affected
For ambidextrous patients- default should be dominant
If the left side is affected the default is monodominant
If the right side is affected the default is dominant

42. Coding guideline: II.C Two or more diagnoses = value
When coding for two or more diagnoses that are of equal value:
With diagnostic testing and treatment for all
Any of the diagnosis may be sequenced first
Organ failure should take precedence if indicated

43. Coding example #1
Susie was admitted with high fever, stiff neck, chest pain, and nausea. A lumbar puncture ws performed and results were positive for meningitis. Chest x-ray revealed pneumonia. Sputum cultures grew pneumococcus. Patient was treated with IV antibiotics. The established diagnoses were pneumococcal meningitis and pneumococcal pneumonia.
What are the codes?

44. Coding Example #1 Answer
Primary:
G00.1 Meningitis, pneumococcal
Seconary
J13 Pneumonia pneumococcal, broncho lobar

45. Coding example #2
Sandy has been taking Haloperidol as prescribed for paranoid schizophrenia. She is being seen for change in facial expressions and stiffness in the arms and legs. Diagnosis is Seconary Parkinsonism due to Haloperido. We have discontinue the drug.
What is her diagnoses?

46. Coding example #2 answer
Primary
G parkinsonism idiopathic primary, secondary, due to drugs. Neuroleptic refer to drugs and chemical
T43.4X5A table of drug and chemicals, Haloperidol, over to adverse effect
F20.0 Schizophrenia, paranoid (type)

47. Coding example #3
A 55 year old female has been diagnosed with breast cancer of the right breast with multiple metastases of the liver. She is seen to control the severe acute pain of the liver metastases.
What are the diagnoses codes?

48. Coding example #3 answer
Primary
G89.3 pain chronic neoplasm related
Secondary
C Neoplasm table down to breast over to malignant primary site
C Neoplasm table down to liver over to malignant secondary site

49. Coding example #4
This patient has type 2 diabetes with neuropathy. She has developed weakness of the left arm and leg. The patient was brought to the ED where she could speak but was unable to use her left arm and leg Diagnostic testing was scheduled: however, the patient completely recovered and was able to move with no deficit within 24 hours. Due to the complete recovery further testing was cancelled. It was determined that the patient experienced a TIA. The patient was also treated for an intractable classical migraine.
What are the diagnoses?

50. Coding example #4 answer
Primary
G45.9 Attack down to transient ischemic (TIA)
Secondary
E diabetes (mellitus) down to type 2 down to with neuropathy
G Migraine down to classical – see migraine with aura; Migraine with aura intractable

51. Chapter 7: Disease of the eye and adnexa
Codes expanded
Increase anatomic specificity and add concept for laterality
If code does not include bilateral and it is needed
Code left
Code right
Many codes specify left or right or bilateral /unspecified

52. Coding example #1
A 50 year old woman presents to her physician office with bilateral eye pain. Her condition is diagnosed as nonulcerative bilateral blepharitis of upper eyelids.
What are the codes

53. Coding example #1 answer
Primary
Blepharitis down to right upper
Secondary
Blepharitis down to left upper